Pennsylvania Department of Health
RICHFIELD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 66 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


RICHFIELD HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on March 1, 2024, it was determined that Richfield Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:
Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, dining area, and food storeroom.

Findings include:

Observation of the facility's main kitchen on February 27, 2024, at 9:20 AM with Employee 1, cook, revealed the following:

A large garbage can in the food preparation area across from the dishwasher was observed with visible dried food and dried liquid runs on the exterior of the can and the lid was not present. The lid was on top of the garbage can next to the handwashing sink.

The cook's refrigerator contained a plastic bag of sliced onions, that were not dated. Employee 1 indicated that nursing staff had leftovers and gave them to the kitchen in case they were needed but they were not used. Also in the refrigerator were the following food items that were not dated with a use-by date or expiration date: six slices of bread, two plastic squeeze bottles of Italian dressing, two sticky plastic squeeze bottles of sauce that was identified as barbeque sauce and two plastic squeeze bottles that was identified as liquid butter by Employee 1, two containers of mustard, two cartons of orange juice, and a partial pack of hamburger rolls. Employee 1 indicated that the items in the squeeze bottles were taken from the original containers to make it easier for resident use at the tables. In addition, in the refrigerator was an open container of beef broth that was not dated with the open date and the label indicated to use within 14 days of opening, a container of tomato sauce with a use-by date of February 25, 2024, a container of tapioca pudding with use-by date of February 26, 2024, a partial tray of yellow cake with chocolate icing that was dated as made on February 23, 2024, and a container of cheesy broccoli soup with use-by date of February 24, 2024. Employee 1 indicated that cooked food is good for three days after making.

The plastic shelving unit contained an open container of drink thickener with the expiration date of February 25, 2024, and a spray bottle labeled as a sanitizer that was stored with the food items.

The shelving unit near the coffee machine contained three bags of homemade cookies with no use-by date, a container of individual coffee creamers without a use-by date or expiration date, bins of single serve condiments (ketchup, mustard, honey, jelly, barbeque sauce, salad dressing, mayonnaise, and syrup) without expiration dates, and a bottle of coconut syrup that was labeled for staff use with a best-by date of December 14, 2023.

The cupboard on the bottom of the steam table housed single serve condiments without expirations dates.

The corner shelf next to the cook's refrigerator contained an open jar of peanut butter with the expiration date of November 6, 2023, a 22-pound container of chocolate icing with a use-by date of January 16, 2024, and a container of flour, two bags of cake mix, and a bag of rice pilaf that were not dated with expiration dates.

The drink refrigerator contained a pitcher of honey-thick lemonade with a use-by date of February 24, 2024, and an open container of Thick and Easy drink without a use-by date. The Thick and Easy label indicated to use the product within 10 days of opening.

Tour of the facility's food storage area was done after the tour of the main kitchen with Employee 2, dietary aide, and revealed the following:

The shelving unit contained the following food items without expiration dates: a bin of flour, a box of graham crackers, three boxes of cookies, and two boxes of oatmeal pies. In addition, a box of cookies was on the shelf with an expiration date of October 24, 2023.

Another shelving unit contained the following food items without expiration dates: brownie and cake mixes, chicken and beef bases, packs of rice pilaf, packs of potato pearls, and #10 cans of food.

The walk-in freezer contained bags of chicken and hamburger without any expiration dates.

The stand-up refrigerator contained the following items without expiration dates: 12 cartons of orange juice and seven packs of luncheon meat. A bag of lettuce that had browning and wilting had a use-by date of February 24, 2024.

The emergency food section contained numerous cans of evaporated milk with an expiration date of January 20, 2024. The canned goods were labeled with Julian dates (dates according to the Julian calendar, that represents the date the food as manufactured or packaged). Employee 2 did not know how to read the Julian dates and determine the use-by dates of the emergency canned food.

The surveyor reviewed the findings for the kitchen and storage area with Employee 3, dietary manager, on February 27, 2024, at 1:45 PM.

The surveyor reviewed the above findings with the Nursing Home Administrator on February 27, 2024, at 2:15 PM.

Observation on February 29, 2024, at 12:10 PM of the facility's ice machine that is in a room in the main dining room revealed there was no visible air gap from the ice machine between the indirect waste pipe and the flood level rim of the waste receptor as indicted in International Plumbing Code 802.3.1 and 802.3.2 of 2018.

The above findings were reviewed with the Nursing Home Administrator on February 29, 2024, at 12:15 PM.

28 Pa. Code 201.14 (a) Responsibility of Licensee

Plan of Correction - To be completed: 04/16/2024

1-A large garbage can in the food preparation area across from the dishwasher was observed with visible dried food and showed no lid--LID was placed on garbage can and garbage can will be cleaned.Refrigerators will be audited ensuring open date is on items along with expiration dates.
The plastic shelving unit contained an open container of drink thickener with the expiration date of February 25, 2024,-This was tossed out. Audit of food items will be completed ensuring dates are on items and any expired items are tossed out.Food items will be audited to ensure food items are stocked and organized with food items only and not mixed with other items.

The shelving unit near the coffee machine contained three bags of homemade cookies with no use-by date, a container of individual coffee creamers without a use-by date or expiration date, bins of single serve condiments (ketchup, mustard, honey, jelly, barbeque sauce, salad dressing, mayonnaise, and syrup) without expiration dates, and a bottle of coconut syrup that was labeled for staff use with a best-by date of December 14, 2023.-ITEMS will be audited and ensured that there is a use date and or expiration date. expired items were tossed out.
The cupboard on the bottom of the steam table housed single serve condiments without expirations dates.-Use date and or expiration date will be added.
The corner shelf next to the cook's refrigerator contained an open jar of peanut butter with the expiration date of November 6, 2023, a 22-pound container of chocolate icing with a use-by date of January 16, 2024, and a container of flour, two bags of cake mix, and a bag of rice pilaf that were not dated with expiration dates. -Expired items were tossed out. Dates will be added to to food items.
The drink refrigerator contained a pitcher of honey-thick lemonade with a use-by date of February 24, 2024, and an open container of Thick and Easy drink without a use-by date. The Thick and Easy label indicated to use the product within 10 days of opening.-Expired items were tossed out. Items were labeled with a use date and or expiration date.
Storage area-The shelving unit contained the following food items without expiration dates: a bin of flour, a box of graham crackers, three boxes of cookies, and two boxes of oatmeal pies. In addition, a box of cookies was on the shelf with an expiration date of October 24, 2023.-Items that are expired will be tossed out. Items will have a use date and or expiration date added.
Another shelving unit contained the following food items without expiration dates: brownie and cake mixes, chicken and beef bases, packs of rice pilaf, packs of potato pearls, and #10 cans of food.-Items that are expired will be tossed out. Items will have a use date and or expiration date added.
The walk-in freezer contained bags of chicken and hamburger without any expiration dates.-ITEMS will be reviewed and expired items will be tossed out other items will be reviewed and audited to ensure a use by date and or expiration date is labeled on food item. All items when opened will have a open date added as well.
The stand-up refrigerator contained the following items without expiration dates: 12 cartons of orange juice and seven packs of luncheon meat. A bag of lettuce that had browning and wilting had a use-by date of February 24, 2024.-ITEMS will be reviewed and items that are expired will be tossed out.
The emergency food section contained numerous cans of evaporated milk with an expiration date of January 20, 2024. The canned goods were labeled with Julian dates (dates according to the Julian calendar, that represents the date the food as manufactured or packaged). Employee 2 did not know how to read the Julian dates and determine the use-by dates of the emergency canned food.-ITMES will be converted over and kitchen staff will be educated on Julian calendar dates.

2-Full kitchen audit of all refrigerators and storage areas will be audited to ensure an open date is labeled on item if open along with a use by and or expiration date.

3-Dietary manager will be educated by NHA to ensure that the Kitchen staff are educated on facilities daily and weekly kitchen audit schedules that are to be completed ensuring compliance with storing and labeling. Julian calendar dates and understanding will be gone over with the kitchen staff.

4-NHA/Designee will audit weekly refrigerators and storage areas ensuring that the facility is using daily kitchen audits and ensuring open dates are placed on items along with having used by date and or expiration date. NHA/Designee will also audit to ensure there are no expired items in storage area/refrigerators as well as audit to ensure kitchen garbage cans are clean and have lids. Audits will be completed randomly weekly x 4 weeks than monthly x 2 months results will be reviewed in QAPI.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on observation, it was determined that the facility failed to promote resident dignity during a dressing change for one of one resident observed (Resident 15).

Findings include:

Clinical record review for Resident 15 revealed a skin/wound note dated February 21, 2024, at 10:01 AM that noted the resident had a sacral (an area overlying the sacrum located at the base of the back) pressure sore.

Current physician orders revealed that Resident 15 is to have wound care and a dressing change daily.

Observation of Resident 15's wound care on February 29, 2024, at 10:30 AM revealed that Employee 5, registered nurse, proceeded to provide wound care and a dressing change on Resident 15's sacral wound without pulling the privacy curtain and in full view of Resident 15's unidentified roommate who was sitting on the other side of the room in a wheelchair in full view of the wound care.

The above information for Resident 15 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 29, 2024, at 2:00 PM.

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct.

2-Facility can not retroactively correct. Employee #5 was educated 1:1 on ensuring privacy curtains are pulled when providing care.

3-DON/Designee will educate Nursing staff on ensuring privacy curtains are pulled all the way when providing care.

4-DON/Designee will randomly audit care/treatments to ensure when providing care the privacy curtain is pulled all the way during care. audits will be completed weekly x 4 weeks and than monthly x 2 months. Audits will be reviewed in QAPI

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations:
Based on clinical record review, and resident and staff interviews, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for one of 14 residents reviewed (Resident 19).

Findings include:

Interview with Resident 19 on February 27, 2024, at 11:57 AM revealed that he moved into his current room in the last few weeks. He stated he was in his old room for "a long time." Resident 19 indicated he did not receive a written notice. Resident 19 stated that the staff did not give him a choice about changing rooms, he stated that he was informed that he had to move.

Clinical record review revealed the facility admitted Resident 19 on October 18, 2022. Review of Resident 19's census information revealed that on February 14, 2024, the resident was moved from room 16 (private) to room 14 (three-bedroom). Further review of Resident 19's census information revealed that Resident 19 had resided in room 16 since February 28, 2023.

Nursing documentation dated February 14, 2024, at 10:00 AM, revealed that Employee 7 (social worker) met with Resident 19 to discuss his room change. She noted per administrative staff and the Department of Health's expectation of having an isolation room, as well as a short-term skilled room for therapy of potential skilled care residents. Employee 7 documented that Resident 19 acknowledged understanding, but stated he liked where he was.

Nursing documentation dated February 14, 2024, at 10:21 PM, revealed Resident 19 expressed anger at being moved when he was at activities in the afternoon. Resident 19 stated "if my blood pressure is up, you know why."

Reviewed findings with the Nursing Home Administrator and Director of Nursing on March 1, 2024, at 10:52 AM.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct. Resident #19 was offered to return back to his old room and declined.

2-Facility can not retroactively correct. Education to be provided to social services by NHA ensuring written notice is given when moving rooms and choice is given to the resident.

3-NHA/Designee to educate social services on room moves/changes ensuring written notice is given when moving rooms and choice is given to the resident.

4-NHA/Designee will audit room moves weekly x 4 weeks than monthly x 2 months to ensure written notice is given to the resident with changing rooms and the resident is given the choice to move. Audits will be reviewed in QAPI.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-Coverage timely, in advance of changes for Medicare covered services to one of three residents reviewed whose Medicare coverage was discontinued (Resident 2).

Findings include:

The form "Notice of Medicare Non-Coverage (NOMNC) CMS-10123," is a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal. The Medicare provider must ensure that the notice is delivered at least two calendar days before covered services end.

Review of Resident 2's Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed that the Medicare skilled A services will end on January 5, 2024.

Review of Resident 2's CMS-10123 form further indicated Resident 2's family was made aware via phone call on January 5, 2024, and verbalized understanding that the coverage of services will end on the effective date indicated on the notice which was also January 5, 2024.

Interview with the Nursing Home Administrator on March 1, 2024, at 10:23 AM confirmed the facility failed to ensure that the notice was delivered at least two calendar days before Resident 2's covered services ended.

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct.

2-Facility can not retroactively correct.

3-NHA/Designee will educate Social services on ensuring notice is delivered at least two calendar days before covered services end.

4-NHA/Designee will audit NOMNC to ensure at least two calendar days is given before covered services end. Audits will be completed weekly x 4 weeks than monthly x 2 months. Results will be reviewed in QAPI.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:
Based on observations and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information and a resident's right to privacy for one of two nursing units reviewed (First Floor Nursing Unit; Residents 6 and 188).

Findings include:

Observation on February 27, 2024, at 11:25 AM of the area outside of the first floor nursing unit near the main entrance to the facility, revealed a medication cart with a computer on top that was clearly visible to anyone passing by. The computer was logged into Resident 6's medical record. There were no staff around at the time of the finding and Resident 6's protected health information (PHI) was clearly visible to anyone passing by. Employee 8, licensed practical nurse, was then observed coming out of a resident's room and started working with the computer. It was unclear how long the resident's chart was left unsecured.

Observation on February 28, 2024, at 11:11 AM of the first floor nursing unit near the main entrance to the facility, revealed a laptop computer that was on top of the desk and visible to anyone passing by. The computer was logged into Resident 188's medical record. There were no staff around at the time of the finding and Resident 188's protected health information was clearly visible to anyone accessing the nurse station. The computer's screen was also visible to anyone coming and going through the front door to the facility. The Director of Nursing confirmed the observation on February 28, 2024, at 11:13 AM and advised the computer belonged to the facility's registered nurse, Employee 9, and proceeded to close the laptop.

The above information for the PHI was reviewed with the Nursing Home Administrator and Director of Nursing on February 29, 2024, at 2:00 PM.

28 Pa. Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct.

2-Facility can not retroactively correct. Lap top privacy screens were ordered during survey to eliminate the possible view of EHR information when walking past the nurses station .

3-Nursing staff will be educated by DON/NHA on ensuring to close lap tops when leaving area at nurses station. Nursing staff will be educated on new privacy screen covers for lap tops.

4-DON/Designee will audit nurses station randomly weekly to ensure computers are not visible when walking past nurses station showing resident EHR information. Audits will be completed weekly x 4 weeks than monthly x 2 months.
Results will be reviewed in QAPI.

483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns:

§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
§483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;

Observations:
Based on observation, resident and staff interview, and clinical record review, it was determined that the facility failed to provide appropriate treatment and services for a resident with an emotional disorder to attain the highest practicable mental and psychosocial well-being for one of two residents reviewed (Resident 13).

Findings include:

During an interview with Resident 13 on February 27, 2024, at 12:39 PM, the resident revealed was in and out of the hospital for hearing voices. Resident 13 indicated that psychiatric visits are done by computer whenever the woman who helps her is available. Resident 13 voiced that the resident could use someone every day for talking.

Clinical record review for Resident 13 revealed that her diagnoses include schizoaffective disorder (a combination of symptoms of hallucinations or a perception of having seen, heard, touched, tasted, or smelled something that his not there, delusions or false beliefs, and mood disorder such as depression or extremely elevated mood). The record included that Resident 13 had two psychiatric hospitalizations from June 2023 to current.

Review of a hospital discharge summary for Resident 13 dated August 24, 2023, revealed the resident was hospitalized since June 22, 2023, for schizoaffective disorder. The reason for admission was increasing hallucinations. The resident reported the hallucinations increased her anxiety. The voices told her to hurt herself or do bad things like steal. At the time of discharge from the hospital, the resident was deemed not to be a threat to self or others. The resident was readmitted to the nursing facility.

Review of a hospital discharge summary for Resident 13 dated February 2, 2024, revealed that the resident was hospitalized since January 19, 2024, for schizoaffective disorder. The reason for admission was the resident experienced auditory command hallucinations (hearing voices that instruct a person to act in a certain way) for several months that the voice wanted to hurt the resident and for the resident to commit murder. At the time of discharge from the hospital the resident was deemed not a threat to self or others. The resident felt nervous about returning to the nursing facility. The resident was readmitted to the nursing facility.

Clinical record review for Resident 13 revealed the resident received psychiatric visits by a nurse practitioner (an advanced practice registered nurse trained to provide mental health services) via telemedicine (using a computer to see and provide care to a person) throughout her stay and most recently on the following dates: October 16, 2023, November 13 and 27, 2023, December 12, 2023, January 2, 16, 2024, and February 4, 13, and 20, 2024.

Clinical record review for Resident 13 revealed no person-centered care plan related to the resident's hallucinations, anxiety, and harm to self or others which included an assessment of the level of the resident's distress, providing individualized treatment and services, programs or activities and the supportive care staff can provide to assist the resident in coping with hallucinations and anxiety. In addition, there was no documented routine assessments of the resident's hallucinations or anxiety.

The facility failed to provide the appropriate treatment and services for Resident 13 to attain the highest practicable mental and psychosocial well-being.

During a meeting with the Nursing Home Administrator, Director of Nursing, and Employee 7, social worker, on March 1, 2024, at 10:30 AM, the surveyor reviewed the findings for Resident 13.

28.Pa. Code 201.18(b)(1) Management

28. Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct. Resident#13 was being seen by the facilities psychiatric/mental health service provider.Resident #13 care plan will be updated to reflect a person centered care plan.

2-Facility will review current residents who have Schizophrenia to ensure a person centered care plan is in place as well as ensuring treatment and services are provided to meet the need of the resident.Resident 13 was placed on increase psychosocial visits with the social worker for emotional support.

3-NHA/DON/Designee will educate Social services and MDS coordinator on ensuring a person centered care plan is in place as well as ensuring treatment and services are provided to meet the need of the residents.

4-NHA/DON/Designee will audit residents who have been identified to have schizophrenia to ensure a person centered care plan is in place as well as ensuring treatment and services are provided to meet the need of the residents. Audits will be completed weekly x 4 weeks than monthly x 2 months. Audits will be reviewed in QAPI.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 32).

Findings include:

Clinical record review for Resident 32 revealed the facility admitted her on November 2, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 32's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 2, 2023, indicated that the facility assessed Resident 32 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 32's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

The findings were reviewed with Employee 6 (RNAC, registered nurse assessment coordinator) on February 29. 2024, at 2:37 PM. Employee 6 confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 32's dementia and cognitive loss.

28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct.
Dementia Care plan was updated and individualized for resident 32.

2-Facility will run a report on current residents who have Dementia and will audit their care plan as needed to ensure dementia care plan is individualized and person centered.

3-NHA/DON will educate MDS coordinator as well as social services on ensuring Dementia Care plans are individualized and person centered.

4-NHA/DON/Designee will audit residents who have a diagnosis of Dementia ensuring Dementia Care plans are individualized and person centered. Audits will be completed weekly x 4 weeks and than monthly x 2 months results will be reviewed in QAPI.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 14 residents reviewed (Resident 20).

Findings include:

Review of Resident 20's medical record revealed a section of the electronic health record (EHR) where various documents are uploaded to the medical record. Further review of this section for Resident 20 revealed that multiple scans for another resident, Resident 191, were uploaded on April 6, 2023, to Resident 20's medical record. The following documents were erroneously uploaded to Resident 20's medical record:

An updated POLST (Physician Orders for Life-Sustaining Treatment form
X-ray results
Status Report
Referral to Rehabilitation Service
Psychological Evaluation and Consult "Jan 23"
Psychological Evaluation and Consult "Nov 22"
Psychological Evaluation and Consult "March 23"
Psychological Evaluation and Consult "Dec 22"
Physician Orders "March 23"
Physician Orders "Nov 22"
Physician Orders "Oct 22"
Physician Orders "Feb 23"
Physician Orders "Jan 23"
Physician Orders "Dec 22"
Physician Notes "March 23"
Physician Notes "Feb 23"
Physician Note
Order Summary "March 23"
Multidisciplinary Therapy Screen
Nursing to Therapy Communication
Labs "Dec 22"
Labs "Nov 22"
Interdisciplinary Rehabilitation Data Gathering and Screening Form
Hospital Documents
Hospital to PAC Facility Form
Hospital Documents
Hospital Documents
Endoprosthesis Identification Card
Family Practice Documents
Controlled Substance Record
Consults
AIMS (Abnormal Involuntary Movement Score) "March 23"
Consent for Psychotropic Therapy
After Visit Summary "Nov 20"
After Visit Summary "Nov 22"
Diabetic Foot Care
Summary Report "Jan 23"

The Nursing Home Administrator and Director of Nursing were informed of the findings on March 1, 2024, at 1:42 PM.

28 Pa. Code 211.5(i) Medical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/16/2024

1-Facility to review and correct uploads ensuring EHR is uploaded in the correct chart. The following documents were erroneously uploaded to Resident 20's medical record and will be reviewed.
An updated POLST (Physician Orders for Life-Sustaining Treatment form
X-ray results
Status Report
Referral to Rehabilitation Service
Psychological Evaluation and Consult "Jan 23"
Psychological Evaluation and Consult "Nov 22"
Psychological Evaluation and Consult "March 23"
Psychological Evaluation and Consult "Dec 22"
Physician Orders "March 23"
Physician Orders "Nov 22"
Physician Orders "Oct 22"
Physician Orders "Feb 23"
Physician Orders "Jan 23"
Physician Orders "Dec 22"
Physician Notes "March 23"
Physician Notes "Feb 23"
Physician Note
Order Summary "March 23"
Multidisciplinary Therapy Screen
Nursing to Therapy Communication
Labs "Dec 22"
Labs "Nov 22"
Interdisciplinary Rehabilitation Data Gathering and Screening Form
Hospital Documents
Hospital to PAC Facility Form
Hospital Documents
Hospital Documents
Endoprosthesis Identification Card
Family Practice Documents
Controlled Substance Record
Consults
AIMS (Abnormal Involuntary Movement Score) "March 23"
Consent for Psychotropic Therapy
After Visit Summary "Nov 20"
After Visit Summary "Nov 22"
Diabetic Foot Care
Summary Report "Jan 23"

2-The NHA/DON/Designee will educate the employee who is/was responsible for uploading EHR information into the wrong EHR charts. Employee will be educated on ensuring proper residents are selected prior to uploading data. A 30 day look back of identified employee uploads will be audited ensuring charts are capturing the proper residents EHR information/data.

3-The NHA/DON/Designee will educate the employee who is/was responsible for uploading EHR information into the wrong EHR charts. Employee will be educated on ensuring proper residents are selected prior to uploading data.

4-The NHA/DON will audit charts randomly weekly x 4 weeks to ensure uploads into residents charts are accurate and under the correct residents name.Audits will be completed weekly x 4 weeks than monthly x 2 months. Results will be reviewed in QAPI.

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:
Based on review of select personnel records, and staff interview, it was determined that the facility failed to implement pre-employment screening procedures for tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) for one of five newly hired employees reviewed (Employee 4).

Findings include:

The Centers for Disease Control and Prevention (CDC) recommendations (https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm) stipulates that all U.S. health care personnel should be screened for TB upon hire (i.e., preplacement) by either a TB blood test or a two-step TB skin test. Information from the baseline individual TB risk assessment should be used to interpret the results of a TB blood test or TB skin test given upon hire (i.e., preplacement). Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease.

Review of Employee 4's (speech therapist) personnel record revealed that the facility hired her on December 28, 2023. The information provided by the facility indicated that there was no evidence in Employee 4's personnel record to indicate that the employee had a TB screening.

Interview with the Nursing Home Administrator on February 29, 2024, at 2:15 PM confirmed that the facility had no further evidence of a TB screening for Employee 4.

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct.Employee #4 is PRN and will be required to have a 2 step prior to picking up any shifts.

2-Facility can not retroactively correct. Facility will complete a 4 month look back on new hires ensuring staff have a 2 step PPD completed and or a CXR.

NHA/Designee will educate HR on ensuring TB pre-employment screening is completed prior to start date on new hires.

NHA/designee will conduct audits ensuring new hires have a 2 step PPD completed and or CXR prior to start date. Audits will be completed on any new hires weekly x 4 weeks and than monthly x 2 months. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 04/16/2024

1-Facility can not retroactively correct.

2-Facility can not retroactively correct, Facility will continue to recruit and retain LPN staff through a variety of services.

3-NHA/Designee will educate the scheduler and IDT on the staffing Ratios.

4-DON or designee will conduct review of staffing deployment assignments daily to ensure the staffing ratio is being met for a period of 4 weeks and a weekly review x 2 months. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement